Mass general covid 19 treatment guideline july012020

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© Copyright 2020 The General Hospital Corporation. All Rights Reserved.
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Massachusetts General Hospital (MGH)
COVID-19 Treatment Guidance
This document was prepared (in March-July, 2020) by and for MGH medical professionals (a.k.a. clinicians,
care givers) and is being made available publicly for informational purposes only, in the context of a public
health emergency related to COVID-19 (a.k.a. the coronavirus) and in connection with the state of emergency
declared by the Governor of the Commonwealth of Massachusetts and the President of the United States. It is
neither an attempt to substitute for the practice of medicine nor as a substitute for the provision of any medical
professional services. Furthermore, the content is not meant to be complete, exhaustive, or a substitute for
medical professional advice, diagnosis, or treatment. The information herein should be adapted to each
specific patient based on the treating medical professional’s independent professional judgment and
consideration of the patient’s needs, the resources available at the location from where the medical
professional services are being provided (e.g., healthcare institution, ambulatory clinic, physician’s office,
etc.), and any other unique circumstances. This information should not be used to replace, substitute for, or
overrule a qualified medical professional’s judgment.
This website may contain third party materials and/or links to third party materials and third party websites for your
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 This document was developed by members of the Infectious Diseases (ID) division at MGH in
conjunction with pharmacy, radiology, and other medicine divisions to provide guidance to frontline
clinicians caring for adult patients with COVID-19.
 This document covers potential emergency use, off-label and/or experimental use of medications
and immunosuppression management for transplant patients as well as a suggested laboratory
work up. It does NOT cover recommendations for infection control, personal protective equipment
(PPE), management of hypoxemia or other complications in patients with COVID-19.
 This is a living document that will be updated in real time as more data emerge.
Table 1: Recommended laboratory work-up for hospitalized patients
Table 2: Risk stratification
Therapeutic recommendations (bacterial / viral coinfections, ACEi/ARBs, NSAIDs)
Table 3: COVID-19 specific recommendations
Table 4: Special populations
Table 5: Brief overview of agents discussed
Modulating host immunity and risk of reactivating latent infections
Figure: Algorithm
What’s New in the July 1, 2020 update:
 Additional information regarding dexamethasone, including more specific guidance regarding
pregnant women guided by the Maternal-Fetal Medicine service
 Updates regarding remdesivir, which is no longer available after 10pm.

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1
The prognostic value of some of these labs is being defined or is not yet proven. For PUI, please refer to COVID-19
Testing Criteria or Infection Control page for biothreats resolution pathways
2
For a primer on liver issues related to COVID19 and treatment, please see our supporting liver document.
3
If beyond 2 weeks hospital stay, inflammatory markers are hard to interpret. Repeat per discretion of primary team.
4
Viral serologies assist for interpretation of ALT elevations, present in ~25% of presentations. Note: follow-up
molecular testing for HIV/HBV/HCV may have longer turnaround times than usual
5
Elevated troponin (> 2 times upper limit of normal) without hemodynamic compromise, can repeat troponin in 24
hours; echocardiogram not necessary unless otherwise indicated. Up-trending troponin with hemodynamic compromise
or other concerning cardiovascular symptoms /signs should prompt consideration of obtaining an echocardiogram.
Table 1: Work-up for diagnosis, prognosis / risk stratification, and/or safety of therapeutics
Suggested for hospitalized patients with confirmed COVID-191
Recommended daily labs (until stable):
 CBC with diff (esp. total lymphocyte count)
 Complete metabolic panel2
 CPK (creatine kinase)
 Ferritin/CRP (first 2 wks of hospitalization)3
Recommended at baseline then every other day (if
in ICU or elevated check daily):
 PT/PTT/fibrinogen
 D-dimer
Link to Guidance from MGH Hematology
For acute kidney injury (i.e. serum creatinine >0.3
above baseline)
 Urinalysis and spot urine protein:creatinine
When MAS/sHLH suspected (rising LFTs, falling
fibrinogen, hypotension, see Immunomodulation):
 ESR
Viral serologies for all patients unless done
recently:4
 HBV serologies (sAb, cAb, and sAg)
 HCV antibody, unless positive in past
 HIV 1/2 Ab/Ag
For risk stratification:
 LDH (repeat daily if elevated)
 Troponin5
(repeat q2-3d if elevated)
 Baseline ECG (QTc monitoring algorithm)
With clinical deterioration, repeat risk stratification labs.
If clinically indicated:
 Blood cultures (2 sets) if bacteria suspected
 IL-6 if Category 2 or 3 risk factors
 β-HCG for women of childbearing age
Radiology:
 Portable CXR at admission
 High threshold for PA/lateral, consider only if
low suspicion for COVID-19 and result would
change management or affect PUI status.
 Non-contrast CT is of limited utility in
definitively diagnosing COVID-19 and should
only be considered if it is likely to change
management or PUI status; check CORAL tool
Following infection control/PPE guidelines:
 SARS-CoV-2 test, if not already performed.
 Routine influenza A/B and RSV tests are not
currently recommended. Routine expanded
respiratory panels may be approved on a case-
by-case basis.
 If bacterial superinfection highly suspected,
routine sputum for gram stain and culture,
Legionella urinary antigen. If
immunocompromised, see next page.

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Suggested for immunocompromised patients: If clinically indicated, consider sending Pneumocystis
DFA from sputum (no induced sputum given risk of aerosolization). If unable to send sputum, consider
sending serum beta-d-glucan. If clinically indicated, consider sending fungal/AFB sputum cultures
Additional diagnostic considerations for candidates for steroids or immunotherapy:
If starting steroids or immunotherapy AND if the patient is foreign-born from a resource-limited
country, experiencing homelessness, or has a history of incarceration AND if there is no past history
of active TB or latent TB infection (LTBI), send T-Spot. Routine screening for TB is unnecessary
for most COVID patients. More explanation is found here, accompanied by a separate flowchart.
Determine severity and prognosis of patients admitted with COVID-19. The severity of
COVID-19 is categorized into mild (symptoms but no dyspnea or abnormal imaging), moderate
(lower respiratory disease w/ SpO2 >94% on room air), severe (SpO2 ≤ 94% on room air), or
critical (ICU). These definitions vary in the literature.
Table 2: Risk Factors for COVID-19 Disease Progression
Epidemiological – Category 1 Vital Signs – Category 2 Labs – Category 3
Age > 50 Respiratory rate > 24
breaths/min
D-dimer > 1000 ng/mL
Pre-existing pulmonary
disease
Heart rate > 125 beats/min CPK > twice upper limit of
normal
Chronic kidney disease SpO2 ≤ 94% on ambient air CRP > 100
Diabetes with A1c > 7.6% PaO2/FiO2 < 300 mmHg LDH > 245 U/L
History of hypertension Elevated troponin
History of cardiovascular
disease
Admission absolute
lymphocyte count < 0.8
Obesity (BMI > 30) Ferritin > 500 ug/L
Use of biologics*
History of transplant or other
immunosuppression*
HIV, CD4 cell count <200 or
unknown CD4 count*
*Not yet proven as risk factors for progression, inferred from other infections. Other factors include
poverty, racism, recent cancer chemotherapy, recent surgery, pregnancy. For more information
about COVID-19 severity, see our supporting risk factors document.
Procalcitonin is not recommended for most patients admitted with COVID-19. It may have
limited utility in those with intermediate risk for bacterial superinfection. Note that from studies to
date, procalcitonin remains low in the first 7-10 days of COVID-19 infection and can rise later on,
even without bacterial superinfection. Repeating PCT is less specific late in the course of COVID-
19 and generally unnecessary. See FAQ.

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Medication considerations:
Anti-infectives
 Routine empiric antibiotics are not recommended. MGH has detected low rates of
bacterial superinfection in COVID-19 patients, consistent with studies from other centers.6
Unnecessary antibiotic use increases the risk of multi-drug resistant organisms and C.
difficile.
 If empiric antibiotics are given, recommend:
o Ceftriaxone 1 gm IV daily + either doxycycline 100 mg PO BID x 5 days or
azithromycin 500 mg PO x 1 then 250 mg PO daily for 4 days.
o For nonpregnant patients, doxycycline is preferred over azithromycin.
o Azithromycin is preferred for pregnant women and patients unable to be upright for
30m to prevent pill esophagitis related to doxycycline.
o Azithromycin is not proven as an adjunctive treatment with HCQ for COVID-19,
and may increase the likelihood of prolonged QTc and arrhythmias.
o If antibiotics started, duration is 5 days. May discontinue if concern for bacterial
pneumonia low (confirmation of COVID-19, classic presentation, PCT<0.2)
 Regularly reassess need for ongoing antibiotics. For all patients with suspected bacterial
pneumonia on empiric antibiotics, reassess for clinical improvement at 48-72h as well as
risk factors for MDROs. For guidance on risk factors for MRSA/MRDO and for antibiotic
de-escalation after 48-72h of empiric broad spectrum antibiotics in suspected hospital-
acquired or ventilator-associated pneumonia, please check link to algorithm.
 Due to low rates of influenza coinfection at MGH, we do not currently recommend starting
oseltamivir on most patients with COVID-19.7
Cardiovascular medications
ACE-Inhibitors (ACEi) / Angiotensin Receptor Blockers (ARBs):
 Continue ACEi/ARBs if already prescribed. Note there is interest in the potential role of
ACE-inhibitors (ACEi) / angiotensin receptor blockers (ARBs) in the pathophysiology of
this disease since the SARS-CoV-2 virus binds to theACE2 receptor for cellular entry. There
are theories these may either help or worsen COVID-19 disease. Currently there are no data
to support either starting or stopping ACEi/ARBs on any patients with COVID-19.
6
He et al, Infect Control Hosp Epidemiol, 2020; Zhou et al, Infect Control Hosp Epidemiol, 2020; Rawson et al, Clin
Infect Dis, 2020
7
If a known flu contact or high suspicion for flu, request approval for testing and start oseltamivir 75 mg BID in adult
patients with normal renal function. Adjust for renal insufficiency. Stop oseltamivir if testing is negative.

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 However, if acute kidney injury, hypotension or other contraindication develops, we
recommend stopping them at that time. After a person is recovering from their viral
syndrome, their home medications can be restarted, and, if indicated, new ACEi/ARBs can
be started if they have a primary indication such as new persistently reduced ejection
fraction.
Statins:
 Continue statins if already prescribed. Cardiovascular disease is a major risk factor for
COVID-19 disease severity. Additionally, statins may help promote antiviral innate immune
response. For a brief discussion of statins and COVID-19, see our statin rationale document.
 For those who have a guideline indication for a statin and no contraindication (eg.
pregnancy), consider starting atorvastatin 40 mg daily. When major drug-drug interactions
with atorvastatin are expected, pitavastatin 4 mg daily (or pravastatin 80mg daily if
pitavastatin not available) are alternatives. If already on a statin, no need to change to these
agents. If elevated CPK >/= 500 U/L or if ALT > 3x upper limit of normal, consider not
starting a statin. Monitor CPK daily if on both statin and azithromycin.
Antithrombotic medications:
 All patients should be routinely placed on routine standard LMWH prophylaxis, with
the exception of pregnant women >=20 weeks gestation who should receive
unfractionated heparin. Please see link for further guidance from MGH Hematology
Other medications:
 Concerns were raised that NSAIDs may worsen COVID-19 disease. This has not been
proven to-date. See FDA statement on NSAIDs dated 3/19/20. Acetaminophen is the
suggested first-line anti-pyretic. If NSAIDs are used, lowest effective dose is suggested.
 Inhaled medications should be given by metered dose inhaler rather than nebulization.
Nebulization risks aerosolization of virus. If nebulized medications given, use appropriate
PPE. For those without pre-existing pulmonary disease, avoid inhaled steroids as they may
reduce local immunity and promote viral replication.
 Systemic steroids. See discussion under COVID-19 specific management in the next
section regarding dexamethasone, which is recommended to patients on oxygen support but
avoided for patients with mild or moderate disease (no oxygen support). Steroids may be
considered if indicated for another reason (e.g. refractory septic shock, multisystem
inflammatory syndrome, pregnancy for fetal benefit, or specific to lung transplant
guidelines, as delineated below). For those prescribed long-term steroids, discuss with
prescribing physician the management of the underlying condition and whether / how to
continue steroids while hospitalized.

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COVID-19 Specific Management:
Guidance is available from NIH and IDSA. MGH-specific recommendations are below.
The following algorithm provides guidance based on available information to-date regarding
possible and investigational treatments. Caution is advised as there are either no data or limited data
for efficacy for COVID-19. As appropriate, these recommendations will be updated frequently to
include new or emerging data. For clarifications or approval of certain agents, please consult
Infectious Diseases.
Remdesivir (RDV): Remdesivir is recommended for severe disease under an emergency use
authorization by the FDA. RDV is currently available at MGH via the algorithm below. RDV may
also be available via compassionate use for pregnant women / children < 18 years of age who do not
meet emergency use authorization criteria.
Data regarding remdesivir include an underpowered trial from China with negative results and a
large randomized control trial showing efficacy in reducing hospital stay and a trend toward
mortality benefit.
Under the emergency use authorization (EUA) and the Partners Allocation Plan, remdesivir
may be used only to treat:
 Adults, children (≥3.5Kg) and pregnant woman with laboratory confirmed COVID-19, AND
 Hospitalized patients with severe COVID-19 defined as one of the following.
o SpO2 ≤ 94% on room air
o Requiring supplemental oxygen
o Mechanical ventilation
o Extracorporeal membrane oxygenation (ECMO)
Remdesivir should not be initiated or should be stopped if ALT is ≥5x ULN. For patients with
eGFR < 30 ml/min, remdesivir may be considered on an individual basis considering risk/benefit
with input from infectious diseases and nephrology. Treatment of mild / moderate COVID-19 with
remdesivir is not currently recommended. Critical disease is defined as mechanical ventilation or
ECMO.
Remdesivir under the emergency use authorization has been offered to patients eligible per criteria
available at this link. To discuss new starts of remdesivir: 1) check eligibility at that link; then 2)
please contact Infectious Diseases. See detailed checklist below.
To access RDV via compassionate use for pregnant or pediatric patients who do not meet EUA
criteria, use this portal.
Due to safety issues with RDV, need for mixture and preparation in the clinical trials pharmacy,
need for different formulations for different patient populations, as well as government
requirements for documentation of assent, we are not initiating RDV after 10pm.

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Dexamethasone is recommended for hospitalized patients with severe COVID-19 (requiring
supplementary oxygen). Systemic steroids should be avoided for patients with mild or moderate
disease (no oxygen support) unless there is another indication.
A preliminary report from the RECOVERY RCT in the UK indicates survival benefit of low dose
dexamethasone for patients with severe or critical COVID-19, but no benefit in those not requiring
oxygen support. Specifically, the mortality benefit was greater in a pre-specified subgroup of
patients receiving mechanical ventilation (RR 0.65, p < 0.001) than in those on supplemental
oxygen (RR 0.80, p = 0.002), with a non-statistically significant trend towards harm in those not on
oxygen (RR 1.22, p = 0.14). The report is not yet peer-reviewed.
Notes for use at MGH:
 Both PO and IV formulations of dexamethasone currently in stock at MGH. Alternatives to
dexamethasone include:
o Hydrocortisone IV 50mg q8hrs (or q6h for refractory shock co-indication)
o Methylprednisolone IV 30mg daily
o Prednisone PO 40mg qd
 Dexamethasone has no mineralocorticoid effect, unlike the above alternatives
 No data are available for the combination of dexamethasone and remdesivir at this time.
 Dexamethasone is a moderate CYP3A4 inducer; review of potential drug-drug interactions
is recommended before initiation. Coadministration with remdesivir is allowable.
 Dexamethasone has fetal effects; please refer to pregnancy section for specific guidance.
 Please refer to the MGH critical care guidelines, once updated, for more specific guidance in
this population. See recent FLARE on the RECOVERY trial.
 Contraindications to dexamethasone use include previous hypersensitivity and uncontrolled
fungal infection.
 Close monitoring for hyperglycemia is recommended, particularly in a person with diabetes
mellitus.
Steroid administration is associated with reactivation of latent infections. Please check section for
further guidance regarding HBV, Strongyloides, and tuberculosis. Routine prophylaxis for
herpesviruses and Pneumocystis is not recommended at this time.

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Suggested Treatment Algorithm Based on Clinical Severity:
(See figure at end of document for schematic layout of algorithm)
Table 3:
Clinical Situation Recommendation Notes / Considerations
All hospitalized patients All patients should receive
standard prophylactic
anticoagulation with LMWH in
the absence of any
contraindications8
For pregnant patients >=20
weeks gestation, UFH is
preferred to LMWH.
For patients with mild or
moderate disease
Supportive care with close
monitoring.
See Table 2 for list of risk
factors
Dexamethasone:
Do not start dexamethasone
unless the patient progresses to
oxygen requirement (severe
disease) or has an alternate
indication for corticosteroids
A trend towards harm was
seen in the sub-group of
patients with the
RECOVERY trial who
were not on oxygen
Remdesivir:
Remdesivir is not recommended
in this patient population at this
time.
While a press release has
announced that remdesivir
has efficacy in moderate
disease, the emergency use
authorization does not
permit use in this
population.
Application for a clinical trial.
Please check link for basics of
clinical trial inclusion and
exclusion criteria.
A Spanish language video
regarding clinical trials for
patients and families is
found at this link.
8
Contraindications include active bleeding or platelet count less than 25,000; monitoring advised in severe renal impairment;
abnormal PT or APTT is not a contraindication. If LMWH contraindicated due to renal failure (Creatinine Clearance <30mL/min),
UFH can be used as an alternative. For clarifications, contact Rachel Rosovsky from Hematology, pager 37021.

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For patients with severe or
critical disease
Remdesivir (RDV) was
authorized by the FDA for
emergency use, but is in limited
supply. Partners allocation plan is
at this link.
1. Check eligibility and
confirm eligible under
Partners / MGB allocation
strategy
2. Contact ID to discuss
candidacy and availability
3. If approved by ID,
download information
sheet for patients and
families. Spanish version
available.
4. Obtain assent from the
patient or designated
proxy and record in chart.
5. After provider has
obtained and documented
assent may write order.
Dosing of remdesivir is
200 mg IV loading dose
following by 100 mg IV
daily for a maximum of 5
days; criteria for extension
to be determined once a
stable supply is
established. Remdesivir
EUA is an order panel and
requires ID approval.
6. Monitor ALT and eGFR
daily, discuss with ID if
eGFR< 30 ml/min,
discontinue RDV if ALT
≥ 5x ULN
RDV remains available via
compassionate use for
pregnant or pediatric
patients via this portal.
RDV is also available
through the clinical trial
ACCT-2, which
randomizes patients to
RDV + placebo vs. RDV +
baracitinib.
Key links regarding
remdesivir:
Partners / MGB
allocation plan
Info for providers
Info for patients/families
English or Spanish
Educational slideset
Assess for drug-drug
interactions before starting.
Discontinue remdesivir
upon discharge regardless
of duration

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Dexamethasone at a dose of 6
mg PO / IV for up to 10 days is
recommended for patients with an
oxygen requirement and/or
requiring mechanical ventilation.
Greater benefit was observed for
patients requiring mechanical
ventilation compared to those
receiving oxygen. Refer to critical
care guidelines for patients in ICU
Assess for drug-drug
interactions before starting.
Candidates for steroids /
immunomodulation with
risk for endemic infections,
click here.
Discontinue
dexamethasone upon
discharge regardless of
duration, unless previously
used as maintenance
medications for another
indication or continuation
required as part of a
clinical protocol/trial.
Application for a clinical trial.
Please check link for basics of
clinical trial inclusion and
exclusion criteria.
A Spanish language video
regarding clinical trials for
patients and families is
found at this link.
For patients with evidence of
cytokine release syndrome
With ID input, tocilizumab
(Actemra) can be considered
Send serum IL-6 level prior
to giving first dose of
tocilizumab
sHLH-like features
With ID input, anakinra
(Kineret) can be considered
multisystem inflammatory
syndrome
Consult infectious diseases,
consider rheumatology consult.
Steroids, IVIG and/or anakinra
can be considered
Current case definition
includes persons <21 years
of age but may occur at
older ages.
Not recommended Hydroxychloroquine (HCQ)
should not be initiated outside of
a clinical trial. Chloroquine has
activity but safety concerns and
should not be used.
Azithromycin and ivermectin are
not proven as treatments for
Chloroquine antagonizes
remdesivir in vitro against
RSV. Chloroquine and
HCQ should not be co-
administered with
remdesivir.

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COVID-19. Only use
azithromycin or ivermectin for
other indications.
Ribavirin, lopinavir/ritonavir are
not recommended
For HCQ or other QTc
prolonging meds, check
ECG prior to initiation
given risk of QTc
prolongation. Guidance for
telemetry is found at this
link. Risk is increased in
patients on other QTc-
prolonging agents.
Consider discharge
monitoring for arrhythmia
via mobile cardiac
telemetry via the EP/Holter
service.

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Table 4: Special Populations
Special Population Recommendation Notes
Pregnancy Protocols for treating non-pregnant
women should be followed, unless
there is an intervention specifically
precluded by pregnancy.
Multidisciplinary evaluation
should include obstetric, infectious
disease and critical care providers.
Obstetricians, working with this
team, will consider when in the
context of a woman’s health status,
fetal well-being and gestational
age, delivery should be
undertaken.
Physiology late in
pregnancy and postpartum
may potentially place
women at risk for more
rapid deterioration.
Steroids: After consultation with
Maternal-Fetal Medicine,
treatment with one of the
alternative regimens may be
considered. If there is concern for
risk of preterm birth,
betamethasone 12 mg IM q24
hours is the preferred regimen for
that indication.
Dexamethasone has
known fetal effects. See
steroid section for
alternative regimens
(hydrocortisone,
prednisone or
methylprednisolone)
Remdesivir is available to pregnant
women and children through EUA
as well as through compassionate
use. For compassionate use, apply
through portal:
https://rdvcu.gilead.com/
Nitric oxide therapy may be
considered. Clinical guidelines are
available at this link.
We are monitoring
whether compassionate
use remdesivir remains
available

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Adjunctive medications:
For DVT prophylaxis, pregnant
women >=20 weeks gestation
should receive unfractionated
heparin rather than LMWH.
If antibiotics given for concern of
bacterial pneumonia, azithromycin
is preferred to doxycycline
On a case-by-case basis, may
discuss statin use with the MFM
service.
See MGH hematology
guidelines
Azithromycin has better
safety data in pregnancy
compared to doxycycline
Limited data on IFN,
tocilizumab
Patients who are foreign-born
from resource-limited
countries (at risk for
reactivation of tuberculosis or
Strongyloides)
If receiving steroids or
immunotherapy AND if no prior
history of latent or active TB ,
please send T-Spot. Click here for
further management advice.
For Strongyloides, treat
empirically with
ivermectin for those
receiving steroids and/or
immunomodulation.
Patients who are experiencing
homelessness, history of
incarceration (at risk for
tuberculosis reactivation)
If receiving steroids or
immunotherapy AND if no prior
history of latent or active TB,
please send T-Spot and click here
for further management advice.
Patients with underlying lung
disease (including asthma or
COPD of any severity, ILD,
etc. Additional guidance for
lung transplantation below)
Please consult Pulmonary for any
PUI or COVID+ patient with
underlying lung disease and either
respiratory symptoms or the need
for supplemental oxygen.
For inhaled
corticosteroids, please
discuss the risk / benefit of
discontinuing this
medication with
Pulmonary.9
Patients with myasthenia
gravis
Please contact outpatient
neurologist or consult inpatient
Neurology for any PUI or
COVID+ patients with
myasthesnia gravis
Avoid azithromycin and
HCQ in patients with
myasthenia gravis; discuss
risk / benefit of COVID-
19 related medications
with Neurology
People living with HIV Please call/consult Infectious
Diseases. HIV with CD4 count
Resource for crushing
HIV-medications
9
Discontinuation of inhaled steroids may precipitate exacerbation of underlying lung disease and there are no data to
suggest that inhaled corticosteroids exacerbate COVID-related morbidity or mortality.

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<200 is a risk factor for
complications of other respiratory
infections. Additional caution in
this group is warranted. Because
people with HIV may also have
other conditions (lung disease,
smoking) or vulnerabilities, they
may be at higher risk for
complications regardless of CD4
cell count.
medications for intubated
patients
Resource for ARV drug-
drug interactions
If IgG <400 Consider IVIG at dose of 25 grams
x1 (unclear benefit)
Note: Titers against
SARS-CoV-2 are likely to
be low in the population
For patients on biologic
medications, disease-
modifying anti-rheumatic
drugs DMARDs, neurologic
disease modifying therapies
(DMTs) and other non-
transplant immunosuppressive
medications
Please contact the primary
prescribing provider about
management of the underlying
condition and medications
Do not abruptly stop prednisone
for patients who are on long term
prednisone; consider taper.
If the primary prescribing
physician is unavailable,
please contact the
respective inpatient
consult team
Abrupt cessation may
precipitate a flare of
underlying conditions
Heart/Liver/Kidney Transplant
Recipients
Guided by transplant and
transplant ID teams – please
call/consult
Consider decreasing
tacrolimus/cyclosporine by 50%,
stop mycophenolate
(CellCept/Myfortic) and
Azathioprine in kidney/liver
transplant patients and reduce dose
by 50% in heart transplant patients.
Kidney patients approximate target
tacro level 3-5 ng/ml, cyclosporine
level target 25-50 ng/ml.
In the setting of ground glass
opacities can consider switching
mTor to CNI (tacrolimus) given
possibility of pneumonitis w/
mTor; discuss with heart transplant
before making switch
Screen for drug-drug
interactions with anti-viral
agents, if they are being
used

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Critical illness – in liver and
kidney – stop all
immunosuppression except for
prednisone if they are on it at
baseline
For outpatients on belatacept,
consider switching to tacrolimus or
cyclosporine starting 28 days after
last dose, to avoid clinic visit.
Levels will need to be checked and
thus institute plan to draw them
without exposing community.
For inpatients on belatacept, do not
administer any further belatacept.
28 days after last dose, consider
adding low dose CNI. For CNI
intolerant, consider increasing
daily prednisone dose from 5 mg
to 7.5-10 mg daily.
Continue low dose prednisone (5
mg) in all patients who were on it
before hospitalization.
Request bronchoscopy only if
significant decompensation, versus
lung biopsy as may be lower risk
for aerosolization and exposure to
staff
Lung transplant recipients Guided by transplant and
transplant ID teams -please
call/consult. These are guidelines
only, immunosuppression requires
case-by-case approach.
No change to usual
immunosuppression (avoid high
levels, tailor to patient)
For all those in ICU or with lower
respiratory tract disease (most
inpatients): pulse
Screen for drug-drug
interactions with anti-viral
agents, if they are being
used

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methylprednisolone 125mg IV q
12 hours
Outpatient management:
prednisone taper 60mg x 4 days --
40mg x 4 days – 20mg x 4 days
then back to baseline
Postexposure Prophylaxis for Healthcare Workers:
 There is currently no proven role for post exposure prophylaxis for people with a known
COVID-19 exposure. No benefit of hydroxychloroquine was seen in a double-blinded
placebo randomized controlled trial. Healthcare workers should follow instructions from
Occupational Health.

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Table 5: Brief Overview of Agents Discussed
For a more detailed overview of trials at MGH, please refer to the Apollo Clinical Trials page.
Agent
(link to package insert)
Classification Target /
Mechanism
Dosing Key toxicities
Antivirals
remdesivir Investigational,
emergency use
authorization
RNA dependent
RNA polymerase
inhibitor
200 mg IV x1,
then 100 mg IV
daily, 5 days for
most patients
Nausea, vomiting, ALT
elevations
favipiravir Investigational RNA dependent
RNA polymerase
inhibitor
Oral, per study
protocol
Elevated uric acid
hydroxychloroquine
(Plaquenil)
Off-label,
investigational
Multiple actions;
prevents binding to
ACE2, presents
transport in
endosome, and
possibly others
400 mg PO BID x
2 doses, then 400
mg daily for a total
5 days
QTc prolongation
Inhaled nitric oxide Off-label,
investigational
Vasodilator, in vitro
virucidal properties
Variable Methemoglobinemia
Immune modulators:
dexamethasone
(Decadron)
Off-label Corticosteroid 6 mg PO/IV once
daily for up to 10
days
Hyperglycemia
Avascular necrosis (rare)
Reactivation of latent
infections
tocilizumab
(Actemra)
Off-label,
investigational
Monoclonal
antibody to IL6
receptor
Dosing for
COVID/CRS to be
determined
ALT elevations; decline
in neutrophils, bowel
perforation if history of
diverticulitis
sarilumab
(Kevzara)
Off-label,
investigational
Monoclonal
antibody to IL-6
receptor
Dosing for
COVID/CRS to be
determined
ALT elevations; decline
in neutrophils, bowel
perforation if history of
diverticulitis
ruxolitinib (Jakafi) Investigational Janus kinase
inhibitor
10 mg BID for 14
days, possible
extension to 28
days
Cytopenias, ALT
elevations, increased
infection risk including
herpesvirus reactivation
baricitinib
(Olumiant)
Investigational Janus kinase
inhibitor
Per research
protocol
Cytopenias, ALT
elevations, increased

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infection risk including
herpesvirus reactivation
anakinra (Kineret) Off-label IL-1 receptor
antagonist
Dosing for
COVID/CRS to be
determined
Injection site reactions,
decline in neutrophils
Selected adjunctive medications
atorvastatin
(Lipitor)
Off-label Cardioprotection;
immunomodulatory
40-80 mg PO daily Avoid if using LPV/r
pravastatin
(Pravachol)
Off-label Cardioprotection;
immunomodulatory
80 mg PO daily
ivermectin
(Stromectol)
FDA-approved Treatment of
Strongyloidiasis
Not recommended
for COVID-19
200 mcg/kg rounded
to the nearest 3 mg x
1 (as tablets are 3
mg each), then
repeat dose next day
Caution with those from
filarial endemic areas
(West or Central Africa)
Maximum dose is 21 mg
Liverpool COVID-19 Drug Interactions: http://www.covid19-druginteractions.org/

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Immune-Based Therapies
IVIG preparations would not currently be expected to have sufficient antibody titers against SARS-
CoV-2 to offer effective passive immunity. Steroids, IVIG and/or anakinra may be considered for
adults who present with multisystem inflammatory syndrome.
At this time (June 15, 2020), convalescent plasma/sera/hyperimmune globulin products are not
available for administration at MGH. A clinical trial is planned.
Specific neutralizing antibodies are under investigation, including a trial at MGH (contact site PI:
Michael Dougan).
Modulating Host Immunity (tocilizumab, sarilumab, steroids)
Background: Cytokine profiles of serum from patients with severe infection with SARS-CoV-2
overlap with those seen in macrophage activation syndrome (MAS) and secondary hemophagocytic
lymphohistiocytosis (sHLH). This response is also similar to CAR-T cell based immune side
effects. Anti-IL-6 and other interventions have been of benefit for MAS, sHLH, and CAR-T cell
toxicity. However, data regarding IL-6, IL-1, or other modulation for COVID-19 are limited at this
time and the timing and efficacy of such treatments have not been determined.
 Dexamethasone is recommended for severe COVID-19.
 For additional immunomodulatory therapies we strongly prefer that the team refer the
patient to a clinical trial, if available. See link for details.
 A multidisciplinary team has convened to provide more clarity regarding off-label use for
those who are not participating in clinical trials; please discuss with infectious diseases.
 Decisions regarding off-label use of immunomodulatory agents should be made with
agreement of both the primary and recommending teams.

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Infections, Steroids & Immunomodulation
Immunomodulation may be associated with increased risk of infections. While steroids should
generally be avoided unless there is another indication, the risk of using other immunomodulatory
agents during infection with SARS-CoV-2 has not been established, Also, it is unknown whether
data from longer term exposure can be extrapolated to the shorter term use associated with
treatments for COVID-19.
Reactivations for viruses such as hepatitis B virus (HBV) or herpesviruses (HSV, CMV, VZV) may
occur in patients receiving steroids or immunomodulation. Also, parasites such as Strongyloides and
intracellular pathogens such as M. tuberculosis may activate years to decades after leaving countries
with higher prevalence of these infections.
HBV: All patients with COVID-19 should be screened for active HBV with HBsAg regardless of
country of origin. Contact ID or hepatology for guidance if receiving steroids/immunomodulatory
therapy.
Strongyloides: We favor empiric treatment in patients who are foreign-born (resource-limited
settings) with ivermectin prior to steroids/immunotherapy rather than checking serology due to long
turnaround times. Ivermectin is safe and recommended treatment is 1 dose of 200 ucg/kg rounded to
nearest 3 mg increment PO x 1 (maximum dose 21 mg), then repeat the same dose a day later.
If a patient is West or Central African, do not give empiric ivermectin due to the potential rare
complication of larval migration with certain filarial nematodes. Screen the patient with a
microfilarial smear (order as a miscellaneous micro test, 2 large purple top tubes) to exclude
concomitant high-titer filarial nematodes. If questions, email Dr. Rocio Hurtado
(rhurtado@partners.org).
Note there is a report of in vitro inhibition of SARS-CoV-2 by ivermectin. It would require 50-100x
standard dosing to achieve in vivo concentrations necessary to inhibit SARS-CoV-2. Ivermectin is
not recommended for COVID-19.
Tuberculosis: For patients who are foreign-born from resource-limited countries or for patients who
are experiencing homelessness or have a history of incarceration, if there is no history of prior
active TB disease or infection, we favor checking a T-spot prior to starting immunotherapy. Proceed
with immunomodulation while that result is pending. Thus far, there are scant data but no indication
that TB reactivation occurs more frequently during COVID-19 illness. If there are concerns for
development of active TB disease during a hospital admission, please contact ID for further
guidance.
If a patient at risk is considering or has started steroids or off-label immunomodulatory agent,
or the patient is entering into a clinical trial of an immunomodulatory agent, please click here
for a flowsheet that has more details and guidance. Apply algorithm even if the patient may be
receiving a placebo.

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Clinical trials team
considers EUA RDV and
clinical trial candidacy
Eligible, willing, and able to
enroll in a clinical trial?
†
Supportive care and close
monitoring
Repeat labs at regular intervals
If progresses to Tier 1 and
becomes candidate for RDV,
contact ID consult pager
❖
Strongly consider dexamethasone 6 mg PO/IV daily for up to 10 days
Consider statin if CV indication
Supportive care, close monitoring, repeat labs at regular intervals
If on remdesivir, follow daily LFTs and eGFR
If not on RDV, may reconsider if progresses and/or continues to qualify via the ID consult pager
❖
Other off-label therapies can be considered with guidance from ID
‡
Oxygen saturation on
ambient air <=94% and
on supplemental oxygen
Refer to MGH ICU COVID
management guidance
If on RDV, follow daily LFTs and
eGFR
Decisions about off-label
hydroxychloroquine,
immunomodulatory or other
therapies can be considered on a
case-by-case basis by the ICU
team, with ID guidance
Enrolled in clinical trial?
§
Confirmed COVID Positive,
Admitted as Inpatient
If candidate for EUA RDV,
discuss with ID
Patient’s location of care
Yes
No
Trial includes
RDV, or
specifically
excludes RDV
trial allows open-label RDV
Yes
No
ICU
Floor
1. Download RDV information sheet
2. Obtain and document assent from
patient or proxy
3. If assent documented, write order
*: See risk factors table (Table 2) in this document
†: Current list of clinical trials is found at this link.
ID strongly recommends referral to clinical trials
‡: Guidance from ID regarding off-label use of
immunomodulators or compassionate /
emergency use remdesivir is available 8am to
8pm
§: Clinical trials may include RDV, may
specifically exclude RDV or allow for open label
RDV from EUA or compassionate use. If the trial
excludes RDV, the patient may or may not decide
to de-enroll should they qualify under the EUA
❖. If not on RDV (eg declined or not qualified
earlier in admission), regardless of clinical trial
enrollment status, patient may be reconsidered
for RDV should they qualify under the EUA.

Mass general covid 19 treatment guideline july012020

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